Transactional and Age-disparate Sex in Hyperendemic Countries
I. Definition of the Prevention Area
Transactional sex (TS) is the practice of exchanging sex for financial or lifestyle rewards. Distinct from formalized sex work, transactional sex is thought to be a fairly common form of sexual partnering in parts of sub-Saharan Africa. Young women may engage in transactional sex with older men to support their basic needs (e.g., food, clothing, school fees) or to obtain desirable consumer goods (e.g., cell phones, fashionable clothing, jewelry, meals at expensive restaurants) and the social status that goes with them. Gifts for sex may be seen as symbolizing the love and respect a man feels for his partner and the importance he places on the relationship. In contrast, "giving away" sex can stigmatize young women as "loose" and lacking self-respect.
"Age-disparate" relationships are those occurring between young people and individuals five or more years their senior. Sexual relationships between individuals 10 or more years apart in age are referred to as "intergenerational" or "cross-generational" relationships. While these relationships take different forms, this document focuses on age-disparate transactional sexual relationships involving older men and young women.
II. Epidemiological Justification for the Prevention Area
Young women and girls are especially vulnerable to HIV due to biological and social factors. For example, unequal access to economic opportunity often compels them to trade on their sexuality. The epidemiological record shows that young women in sub-Saharan Africa are two to four-and-a-half times more likely to be living with HIV than their male counterparts. There is compelling evidence that these gender disparities stem in part from the frequency of age-disparate and transactional sexual networking in parts of sub-Saharan Africa.
Transactional sex, which has been strongly associated with increased risk of HIV among young women, is common in the region. One recent study, conducted in South Africa, found that nearly a quarter of all young women respondents report ever having sex with a non-primary male partner (for example, a man who is not her husband or boyfriend) in exchange for material goods or money. Other studies report similarly high levels of transactional sex among youth in Africa, ranging from 2 percent among some young women in Tanzania to 90 percent among 15- to 19- year-old women in one Ugandan study. Transactional sex often occurs as a feature of age-disparate sexual networks (because older men are likelier than boys to have the means to offer gifts for sex) or of multiple concurrent partnerships. Even independent of these contexts of increased risk, women may have less power to negotiate condom use when engaging in transactional sex.
Age-disparate sexual relationships put young women and girls at heightened risk because older men often have higher HIV infection rates than adolescent boys or young men. The age disparity may also decrease a young women's ability to negotiate for safer sex for a variety of reasons, including not wanting to challenge an elder. Various studies have shown that these relationships are common throughout sub-Saharan Africa and that they are associated with unsafe sexual behavior, low condom use, and increased risk for HIV. One study in Zimbabwe provided clear evidence that age-disparate sexual networking explains gender differences in HIV infection rates among youth in that country.
III. Core Programmatic Components
Effective programming to address age-disparate transactional sexual relationships builds upon the social and cultural contexts that influence sexual behavior. Promising practices have included a combination of microeconomic approaches (such as small loans or conditional cash incentives), interpersonal and community activities (such as support groups, youth groups, mentoring programs, and clubs), and broad-scale interventions using the media. These activities challenge social norms that condone age-disparate sex and give girls support and information to empower them to make healthier choices.
The greater involvement of men in prevention programs that challenge gender and other social norms is another important programmatic component. Examples of such programs include Program H, which promotes gender-equitable norms among young men, and Men as Partners, which works with men to address gender norms, improve access to reproductive health care, and reduce intimate partner violence.
Some programs, like the Stepping Stones strategy, help communities discuss and identify their own solutions to the risks associated with normative sexual practices. Finally, more studies are needed to better understand and evaluate the cultural factors in transactional and intergenerational partnerships, their associated risks, and the impact of interventions to address them.
IV. Current Status of Implementation Experience
While the effect of age-disparate and transactional relationships on HIV epidemics has long been understood, these factors have only recently emerged as salient dimensions of the hyperepidemics in Southern Africa. Large-scale programming to address these issues is in its infancy, with new anthropological research expanding knowledge of the cultural issues underlying sexual risk.
Moving forward, programmers must identify and account for possible variations in the populations engaged in transactional sexual relationships, where age disparities are and are not involved, and how these various forms of sexual partnering affect HIV vulnerability in different settings. Successful programs will also be based on an understanding of specific social norms that influence transactional and age-disparate sexual relationships. It will then be critical to integrate such knowledge into combination prevention programs addressing the biomedical, cultural, behavioral, and structural factors contributing to sex-related HIV risk and vulnerability.
Focus group discussions among women ages 15-24 and men ages 40-55 in Botswana, Namibia, and Swaziland about intergenerational (IG) sex confirm previous findings from southern Africa: the practice is common; rural and urban diffferences exist in the nature of the goods for which women exchange sex; men engage in the practice seeking physical gratification; and condoms are infrequently used in these relationships. This study also found that men and young women engaging in IG sex felt their partners were more likely to be infected with HIV than a partner their own age. Despite this knowledge, they were willing to continue involvement in such relationships without using condoms. Women often discussed their older partners in depersonalized and disparaging ways, using various nicknames such as "ATM" or "my stupid one." The researchers conclude that HIV prevention efforts targeting older men can capitalize on this information about how younger women ridicule them. Furthermore, providing young women with alternative means of financial support may reduce their willingness to enter into IG relationships.
This ethnographic study among young college women in Zimbabwe challenges the common assumptions that 1) young women engage in age-disparate transactional relationships in order to provide for their basic needs and 2) that these relationships are always sexual. While they pursued higher education, the basic living needs of the 10 young women interviewed were supported by their middle-class parents. These women sought out relationships with older off-campus men in order to obtain access to consumer goods and other resources necessary to be recognized among their peers as fashionable and of a higher status. While sex is often desired or requested by their older suitors, these young women deploy a range of strategies to avoid sexual contact and are generally (if not always) successful.
Conducted among youth ages 14 to 25 in nine rural villages in Tanzania, this ethnographic study examined young women's motivations to exchange sex for gifts or money. Study participants generally were unmarried with only primary schooling. Transactional sex (TS) was common and not considered immoral; participants saw the exchange as both parties gaining what they wanted. Furthermore, participants alluded to family member complicity in certain TS situations. Most relationships were formed on the basis of financial gain: romantic love or finding a marriage partner were rarely factors. Although macro-level factors influencing TS primarily benefit men, micro-level factors benefit both men and women. The authors further identified four ways that TS likely increases risk of HIV infection in this setting. Because TS is so strongly embedded in this culture, any attempts at harm reduction among this population must be carefully designed and piloted.
This ethnographic research studies TS in rural Tanzania within the context of family relationships. Young people aged 14 to 24 years and their parents were observed and interviewed; follow-up interviews provided clarification on important themes emerging from the first set of interviews. Generally, everyone--parents and youth alike--was in favor of TS. A woman's body was seen as a commodity. Participants explained that only women who did not value their self-worth would have sex without any exchange. Such women were looked down on by others, seen as stupid or easily cheated, worth nothing, and thus equated with prostitutes. Furthermore, the exchange of goods or money was symbolic, signifying seriousness or love. Women often felt that they were exploiting men, and thus TS was a way for women to exert power. Despite knowing about the risks to sexual and reproductive health, women generally did not use contraception. Because TS appears to be a social norm, risk reduction programs may focus on encouraging women to include safer sex in their negotiation for gifts and money.
While attention and research have focused on "sugar daddies" posing an increased risk of HIV to young women in sub-Saharan Africa, few studies have gathered epidemiologic HIV data within age-disparate relationships. This study examined the relationships and sexual behavior of 1,313 men in beer halls in Zimbabwe at the peak of the HIV epidemic (2002-2003). Nearly half of the interviewees reported having more than one sexual partner in the six months prior to the interview. Furthermore, nearly two-thirds reported at least one partner five or more years younger, many of whom were their wives. Only 2.5% of the relationships met the "sugar daddy" criteria. Unexpectedly, the study found that the younger the female partner was, the greater the likelihood of condom use. There was no association between a man's positive HIV status and his engaging in intergenerational (IG) sex. The men reported lowest levels of condom use with their wives and steady partners. This suggests that while age-disparate relationships are a concern for a sustained HIV epidemic, conventional IG relationships--that is, married and long-term couples--pose a greater risk of HIV infection than "sugar daddy" relationships. Publicizing the dangers of age-disparate relationships may be one way to address this issue, as would changes in social norms that would enable women to negotiate safe sex, regardless of their age. Weaknesses of the study include not interviewing the female partners and that the men may not be representative of the broader population, as alcohol use is a known risk factor for HIV infection.
This qualitative study explores the underlying cultural contexts in which sexualities are formed and sexual practices performed in southern Africa. The author argues that practices of multiple, concurrent, and transactional relationships are "interlinked and should be considered together as key cultural scripts that prescribe for the practice of normative transactional sex." One such cultural script suggests that giving gifts commensurate with their wealth is one way men in the region demonstrate "love, commitment, or affection" to their sexual partners. Men here feel compelled to share their wealth with sexual partners as a way of showing respect, and expressed the belief that only morally "loose" women would ever give sex for free.
Secondary analysis of data collected for an HIV behavioral prevention study informs this research on men's views of TS from 70 villages in the rural Eastern Cape Province of South Africa. Researchers assessed TS practices with primary girlfriends and casual partners, including whether men received resources from female partners. Nearly 20 percent of the men interviewed gave material resources to casual partners, but only 7 percent received from casual partners. Among main girlfriends, giving and getting resources were nearly equal (15 percent versus 14 percent, respectively). Interestingly, men who gave and received resources were equally likely to report controlling and violent behaviors, including perpetrating interpersonal violence. Furthermore, TS was correlated to sexually assaulting women. The authors concluded that, "TS should be viewed as a part of a cluster of sexually violent and controlling practices." This research suggests that interventions must focus on changing the idea that masculinity means success with and control over women, rather than work to reduce individual HIV risk behaviors.
In-depth interviews and focus group discussions took place among men and women ages 16 to 24 years in Dar es Salaam to identify their HIV risk factors. The researchers found TS emerging as a major theme in every discussion. Interviewees identified two types of partners: 1) regular, "true love" partnerships and 2) casual partners. The connection between sex and money was explicit in casual relationships. While such an exchange was also expected in the committed relationships, it was not the primary motivation for the relationship. Men generally engaged in partnerships for sex, while women entered them for social status, the eventuality of marriage, and money. Some women reported engaging in TS as a survival strategy. Men also reported forcing women to have sex after paying for drinks or entrance into a disco, and feeling justified in doing so. Women in committed partnerships, however, could express their sexual desires, refuse sex, and negotiate condom use with their partners. The authors conclude that TS has implications for HIV prevention programming and should be a part of comprehensive youth HIV prevention efforts.
In-depth interviews among youth in the Balaka district of Malawi dispel traditional "sugar daddy" myths and indicate that money and gifts are a part of traditional courting traditions. In these rural areas, premarital partnerships are the norm, as is providing the female partner with money and/or gifts to show love and affection. Often, this relationship is the precursor to marriage. For men, it is a point of masculinity to be able to provide a partner with money that women can use for luxury items. Among couples who may be together without claiming "true love," there are some TS aspects to the relationship. Contrary to prevailing beliefs about women being disempowered, the interviews found that the woman decides whether she wants to enter into a relationship. Furthermore, she is free to end the relationship any time she wishes. Girls often informally ask about potential partners' sexual behavior as a strategy to minimize HIV risk, but condom use is generally not very high among these partnerships.
This qualitative study explored the factors that help school girls in Botswana avoid IG relationships. The girls who were able to resist relationships with older partners had a number of attributes and beliefs such as having a strong sense of self-worth, accepting their economic circumstances, and wanting to maintain power in decision making. Themes relating to social and cultural factors also played a role. For example, the girls had respect for marriage and believed that older people should be regarded as parents. They also reported religious beliefs and school connectedness. The authors recommended adapting these practices and program approaches into their HIV and AIDS prevention programs to empower girls to resist IG relationships.
Using qualitative evidence from rural Malawi, this anthropological analysis concludes that patron-client ties and a moral obligation to support the needy, fundamental to African social life, are central elements of TS. The study finds that men's relative wealth may compel them to take sexual partners; that, for women, TS may be a pathway to social mobility and economic independence; and that the ties that derive from the exchange of sex for money are one form of patron-client interactions that are part of many African societies.
Nearly 200 women aged 16 to 25 years from Central Maputo, Mozambique, participated in ethnographic research to understand their sexual behavior. The women classified sexual relationships into groups: 1) the namorados (same-age boyfriends with whom there is a perception of trust); 2) pitos (partners for sexual pleasure and no economic exchange); 3) sengue (older married men); and 4) amante (lovers). They consider sengue and amante to be transactional relationships. Women saw such relationships as a way to empower themselves socially and economically. They did not view TS as sex work because it takes place within a relationship. Because these women generally lack educational and occupational opportunities and can only earn low wages, TS offers them a way to advance. While having a sengue is seen as a source of status and pride among their peer group, these women keep such a relationship secret to avoid being labeled a whore--and to avoid losing access to an economic resource. Knowledge of HIV is high among these women, but they do not attempt to negotiate condom use because they do not want to risk losing their relationship and resources that come with it. Because TS is seen as a way to advance among these women, any behavior change interventions must address the loss of power and status that comes with such relationships. Furthermore, interventions must also target the men in these relationships.
This paper explores meanings of sexual exchange for material gain in an urban township of Durban, South Africa. Finding that sexual transactions are not always an outcome of wealthier men exploiting women's need for subsistence support, TS can also be a product of a burgeoning globalized consumer culture. This culture is producing "wants" that may be felt keenly by some women as "needs," with TS "perceived as 'normal,' leading many women to accept men's multiple partners and to put themselves as risk of contracting HIV/AIDS--despite having knowledge of the pandemic." The paper also highlights the role of women's power and agency, arguing that women see their sexuality as the only means at their disposal to obtain what they perceive essential "commodities of modernity." Recommendations include ensuring women's access to and control over economic assets.
This article is based on ethnographic research conducted in the South African township of Mandeni. The article compares different forms of TS in two different areas--one a very poor informal settlement and the other an established township--and finds that sex linked to subsistence is more prominent in the informal settlement while sex linked to consumption is more prominent in the township. It argues that this distinction--although not clear-cut--can be attributed to both the different structural positions of women and the contrasting economic stability and historical backgrounds of the two areas. Three factors, the author argues, lead to TS. First is the privileged economic position of men, which provides a material basis for TS. Second are social norms that encourage men to have many sexual partners. Third is the role of women's active agency in TS arrangements: "women approach transactional relations not as passive victims, but in order to access power and resources in ways that can both challenge and reproduce patriarchal structures."
Questionnaires, in-depth interviews, focus group discussions, and role plays among 110 secondary school students ages 14 to 20 years old informed the findings on youth sexual relationships in rural Uganda. Money played an important role in negotiation of sex: the more money a boy had, the greater his bargaining power. While gifts could be exchanged in a platonic relationship as well as a sexual one, money entering the negotiation explicitly equaled sex for these youth. Older partners were coveted by virtue of their ability to give their partners more money. Sex was often seen as girls' "solution to their problem" of a lack of spending money, with money earned through TS spent on necessities as well as luxuries. Interestingly, virtually all boys and girls agreed that even if a girl possessed unlimited monies, sex should never be given away for free. While some students experimented with condom use, most did not use them regularly. Furthermore, the girls said it was the boy's responsibility to procure condoms and discuss their use. The authors state this research indicates that HIV interventions focusing on delaying sex or reducing partners did not have an effect on this study group.
This paper reports on a short-term evaluation of an HIV educational program designed to address sociocultural risk factors among adolescent girls (aged 10-17 years) in sub-Saharan Africa. The program, adapted from a U.S.-based program called "Making Proud Choices," combined skills training to encourage participants to consider alternatives to TS for financial support and an interactive computer-based program about the risks of age-disparate sexual relationships. The post-test showed significant improvements in HIV-related knowledge and self-efficacy to address HIV and sex in relationships with boys and men. Nevertheless, many still reported that a sugar daddy could give a girl what she needed. The authors note, "It is not surprising that this attitude persisted because the financial and social drivers of these relationships have not been changed."
Out-of-school female youth is a difficult-to-reach target population in HIV prevention interventions. This program involved working with 36 out-of-school female youth as researchers, then using the research results in the design and implementation of an HIV project. It was found that young women shared more information with the peer researchers than they would outsiders. Community-wide events for parents were also implemented such as theater performances and house visits. Some young women reported that their parents encouraged them to engage in IG sex. The study also found that female-targeted activities would have more impact on this target group than joint male/female youth programs. Involving out-of-school female youth throughout the research and program design process and involving parents in activities to reduce TS are the good practices demonstrated by this project.
Despite emerging evidence of declining HIV prevalence in countries such as Uganda, the levels of infection and vulnerability among young women aged 15 to 19 years in countries such as South Africa and Botswana remain unchanged, pointing to a continuing failure of HIV prevention efforts in this age group. It is crucial that proven interventions such as delayed sexual debut; reduced numbers of sexual partners, particularly concurrent partners; reduced age-disparate sex; increased condom use; increased male circumcision; and greater access and use of HIV counseling and testing services be implemented concurrently and scaled up to national coverage levels. Fully engaged and committed leadership at the local and national level is needed in order to implement these activities concurrently. These activities must be guided by strategies and processes defined by local communities to address their specific contexts and the existing gaps from the state to individual levels.
HIV incidence among youth in Zambia does not seem to be decreasing, and female youth are more likely to be infected than boys. Higher-risk behaviors such as IG sex, TS, and multiple concurrent partnerships are normalized. The education sector is attempting to address these behaviors through an in-school intervention called CHANGES2, which targets primary school students and addresses barriers to safer sexual behaviors at both the individual and community levels. School-community partnerships are formed to identify and analyze local risk factors. Some risk factors that were identified included student-teacher sexual relationships, gender roles that support men in having multiple partners, and lack of economic opportunities for girls. Data showed that including these partnerships into the program has had a significant positive effect on attitudes toward more equality in gender relations and a decreased tolerance for gender-based violence.
Research with men and boys shows how inequitable gender norms influence how men interact with their partners, families, and children on a wide range of issues, including preventing HIV and sexually transmitted infection transmission, contraceptive use, and physical violence against women and between men. This review assessed the effectiveness of programs engaging men and boys in achieving gender equality and equity in health, highlighting successful program characteristics. It found that well-designed programs did lead to changes in attitudes and behavior. Programs considered "gender transformative" had a higher rate of change than did the other types of programs. Furthermore, integrated programs were more effective in producing behavior change. Behavior change occurred in all program areas and in all types of programs, but relatively few programs involving men took place over the long-term.
This extensive review of IG sex examines the range of programmatic approaches available to prevent or reduce IG sex. The review uses the "continuum of volition" framework used by Save the Children to explore the drivers of IG and TS. The framework assumes that not all young people are vulnerable and/or passive in entering cross-generational sexual relationships. Some empowered youth choose to engage in relationships for "security gains" (emotional or economic). Further along the continuum, "economically rational sex" ranges from sex for "desired material benefits" to sex for survival. At the other end of the continuum are coerced sex and sexual violence, where young women and boys are forced to participate. This end represents power asymmetries and lack of regard for women's and girls' health and well-being. The review looks at the approaches used by existing programs to address IG and TS such as 1) creating youth livelihood opportunities; 2) mobilizing and empowering youth to adopt healthy lifestyles; 3) social advocacy; 4) social marketing and "edutainment"; 5) health education and youth rights; 6) addressing power asymmetries, inequity, and poverty; and 7) addressing social and gender norms, including working with men. Despite a gap in concrete evidence on how to reduce TS and IG sexual relationships, the review includes 10 recommendations programs can incorporate into their activities and strategies to reduce TS and IG sexual relations.
This brief describes Stepping Stones, an HIV prevention project that focuses on developing more gender-equitable relationships. Data from project efforts on the Eastern Cape of South Africa found decreases in HIV and herpes infections among men and women participating in the project, although decreases were not statistically significant. While TS behaviors generally remained unchanged, men participating in the project reported a statistically significant decrease in sex partners at one and two years of follow-up. Qualitative research indicates that profound changes in communication took place among partners, particularly among men and how they related to others. Changes in individual attitudes as a result of the project intervention can ultimately affect HIV rates through providing participants with knowledge about HIV risks, raising awareness of personal risks, and fostering a culture of openness about HIV in the intervention communities.
The drivers of IG and TS relationships occur along a "continuum of volition." This continuum suggests that not all young people are vulnerable and/or passive when involved in sexual relationships with persons who are older or more powerful. Rather, there are empowered youth who choose to engage in sexual relationships with older people for emotional reasons; young people who engage in "economically rational sex" for material things such as clothes or passing grades; and youth involuntarily coerced into sex. This paper reviews the use of a program planning tool to locate individual adolescent girls along the continuum and develop appropriate strategies to resist unwelcomed propositions from men in Malawi. The authors suggest that more reflection is needed on why IG and TS are defined as problematic and what aspects are of concern given that IG relationships occur all over the world. When defining TS and IG relationships as problematic, it is important to understand the choices, or lack thereof, that young women have and to address concerns of inequality within the socioeconomic context in which they occur.
This website contains all of the communication materials used for the YEAH Initiative in Uganda. A program developed to prevent HIV and unplanned pregnancies while keeping young people in school, this national multichannel program is for youth, by youth. Materials include audio episodes from a radio serial drama, DVDs on life choices, pamphlets, posters, and games.
This webpage provides an entry into the work of the Men as Partners project, established in 1996. The program has worked in over 15 countries worldwide to engage men in playing constructive roles to promote gender equity and health. This has been achieved through holding workshops, improving male health care service delivery, public education, and building advocacy networks. Links to video and slideshows, technical resources, and country project websites can be accessed from this main page.
This second in a series of tools encapsulates essential information on identifying appropriate livelihood programs for adolescent girls at increased risk of HIV. Designed for program managers, short briefs present information on gender-based constraints, opportunities, livelihood options, and program information for different demographic groups. The economic support needs of a married, out-of-school, working rural girl, for example, are different from those of an unmarried, urban schoolgirl. Programming matrices in the appendix elaborate on each livelihood approach and include elements of success, cautions, participant profiles, program description, and evaluation results of existing programs.
Stepping Stones is an HIV prevention program working to improve sexual health through building stronger, more gender-equitable relationships with better communication between partners. Started in Uganda, the program has been used in over 100 countries. It uses participatory learning techniques to develop communication skills between partners, self-awareness and knowledge about sexual health, and the consequences of risk-taking. Stepping Stones developed a manual to train and educate men and women for up to 18 weeks, during which time participants critically assess the societal norms and values influencing their attitudes and behaviors and identify changes they should make in order to protect themselves and others from HIV. This training helps bring about more general life changes and improvements, such as improved communication with their partners and children, more understanding and caring for others, and increased self-respect.
Technical Meeting on Young Women in HIV Hyper-endemic Countries of Southern Africa: Intergenerational/Age-disparate Sex: Policy and Programme Action Brief
Leclerc-Madlala, S. (2008).
This short action brief summarizes the issue of age-disparate sexual relationships in Southern Africa and the effect such relationships have on hastening HIV transmission. A meeting of technical experts reviewed the information on this phenomenon and developed seven action and policy recommendations to reduce the risk of HIV among this high-risk group. Recommendations include rapidly increasing programs that work directly with men to challenge the norms that sanction age-disparate sex; involving faith-based/traditional leaders and media more fully; and ensuring that laws against underage sexual exploitation are in place and enforced.
View Report (PDF, 120 KB)
Addressing the Vulnerability of Young Women & Girls to Stop the HIV Epidemic in Southern Africa
U.N. Joint Programme on HIV/AIDS. (2008).
The brief situation analysis in this report identifies multiple reasons for the lack of success in reducing high levels of HIV infection in southern Africa. An expert meeting in 2008 attempted to understand the challenges in preventing HIV in this context as well as identify ways to respond to them. Participants represented high-level policy experts as well as research and programming experts on women, girls, and HIV from all southern African countries. The report contains four key actions to respond effectively to the high levels of HIV infection among young women and girls in this area. Issues briefs in the report include information on priority interventions to reduce women's biomedical vulnerability to HIV and gender-based violence.
View Report (PDF, 1.13 MB)
Cross-generational Sex: Risks and Opportunities
Feldman-Jacobs, C., & Worley, H. (2008).
This brief summarizes the key information of a desk review on cross-generational sex, including prevalence of the phenomenon according to survey data, the consequences to sexual and reproductive health, and conceptual frameworks for understanding the issue. The brief further presents existing programs and approaches, promising practices, lessons for the future, and identifies key research gaps, particularly in evaluating the effect of programs on sexual behavior.
View Report (PDF, 404 KB)
Protecting and Empowering Adolescent Girls: Evidence for the Global Health Initiative
U.S. Agency for International Development. (2010).
This webpage contains the agenda of a cooperating agency meeting focused on protecting adolescent girls from risks of HIV and other reproductive health risks. The evidence from this meeting will be used to inform development of women- and girl-centered approaches in the U.S. Government's Global Health Initiative. Links to resources include a list of key documents recommended by participants, presentations, and a summary of the meeting.